Leroy EdozienConsultant in Obstetrics & Gynaecology
St Mary’s Hospital, Manchester, UK
Introduction
Clinicians’ fundamental principle: “first do no harm”
1 in every 10 patients suffers a medical accident
Systems should be in place to reduce the risk of harm and to mitigate the consequences of error
Patient safety initiatives should be integrated
Risk management is........a systematic approach to reducing risks & improving patient safety
Risk management is not........just about avoiding litigation....limited to incident reporting
RADICAL An integrated systematic framework for
introducing risk management
monitoring risk management
facilitating learning from patient safety incidents
RADICALRaise AwarenessDesign for safetyInvolve service usersCollect & Analyse patient safety data
Learn from patient safety incidents
RAISE AWARENESS
Promote awareness and understanding of patient safety; engage clinicians
•Epidemiology and psychology of error•Working in teams •Training and education•Risk management forums•Communication strategy•Appraisal and accountability
DESIGN FOR SAFETY
Deliver women’s health care in a way designed to protect patient safety
•Standardisation (guidelines, protocols)•Effective communication: SBAR (Situation,
Background, Assessment; Recommendation/Request/Response)•Crew resource management•Care bundles•Handover•Debriefing •Consent
COLLECT AND ANALYSE
Provide efficient systems for collecting and analysing data on safety of care
•Safety culture measurement•Proactive/prospective risk analysis•Incident reporting •Case notes review•‘Root cause analysis’•Benchmarking
INVOLVE USERS
Involve service users in enhancing the safety of women’s health care
•Awareness of hazards in care pathway•Making patient safety interventions•Reporting patient safety incidents•Feedback on safety of care
LEARN FROM INCIDENTS
Nurture an environment that facilitates learning from
patient safety incidents
•Safety leadership at Board level•Identification and pursuit of patient safety indicators•Feedback from risk analyses•Evidence of learning from risk analyses•Develop evidence base for safety interventions•Safety climate monitoring•Integrate risk analysis with clinical audit, complaints, claims and training•Learning at organisational, team and individual levels
Reference
Edozien LC. Gynaecological Risk Management. In Mahmood T, Templeton A, Dhillon C (eds.), Models of Care in Women’s Health, RCOG Press 2009